Zirconia All-Ceramic Restorations:

Do They Perform Well?

Ahmad Jumah
BDS(Hons), MSc/PhD (Clin) Student-First year
Restorative Dentistry Department, Leeds Dental Institute, University of Leeds, UK
dnaahj@leeds.ac.uk

The extensive use of ceramics in industrial, medical and

dental fields makes this period of time a good candidate
to be named as the Ceramic age (Vagkopoulou et
al. 2009). In dentistry, PFM (Porcelain Fused to Metal)
restorations are among the most commonly prescribed and
serviceable restorations with the longest and most traceable
record of predictable performance. However, driven by
the extraordinary increase of aesthetic demands, concerns
about allergies and systemic effects of metal alloys, and
adverse effects of destructive tooth preparation for PFM
restorations, light has been shed on all-ceramic restorations
and rigorous research and development in this field has
been performed. The ambition of complete replacement
of PFM restorations with all-ceramic counterparts was
curbed by the brittleness and limited flexural strength of the
latter especially in areas subjected to high occlusal forces.
Development of high strength zirconia and alumina cores
seems to be potentially effective to overcome this problem.
Partially stabilized zirconia based ceramics have distinct
mechanical and optical properties and exhibit a very
high biological compatibility with the oral environment:
consequently, huge amount of research has been
directed toward this material. Thus, clinicians should
be aware of the current evidence and literature about
zirconia all-ceramic restorations and their clinical
serviceability in order to communicate with patients on
solid scientific bases, clearly describe pros and cons
of such restorations, and deal with the material in the
proper way to guarantee better longevity.
As is the case with all new dental materials, clinicians
should bear in mind that the evidence available about
zirconia is largely based on in vitro studies that might be
inapplicable to some clinical situations and the long term
clinical trials are scarce. In general, clinical data about
this material is of a short term and unfortunately, many
contradictory findings are present. This article briefly
envisages these findings, and attempts to establish a
well-structured argument that will help the reader to
get a broader image about the performance of these
restorations in terms of their functional, aesthetic, and
biological characteristics.
Recently, zirconia or Ceramic steel has been used
extensively in fabrication of extra-coronal restorations

| 8 | Smile Dental Journal | Volume 6, Issue 2 - 2011

especially, crowns and FPDs (Fixed Partial Dentures).

This is largely attributed to the excellent mechanical
properties the material exhibits and increasing
popularity of CAD/CAM technology. The evidence
from experimental work by Guazzato et al. 2004
indicates that the core of the all-ceramic crown dictates
the fracture strength of the restoration. Thus, utilizing
zirconia as substructure guarantees high success rate for
such restorations. Clinical trials studying the performance
of zirconia single crowns are few; most clinical trials
examined the performance of multiunit restorations. In
their 3-year clinical study, Beuer et al. 2010 reported
that none of fifty single crowns failed at the end of the
observation period. However, fractured lingual cusps of
all-ceramic crowns used to restore mandibular molars is
a frequent technical complication that has been reported
by Raigrodski et al. 2006. Area-specific modification of
the core design and thickness was suggested to increase
support for the veneering porcelain. Silva et al. 2010
found increased reliability of modified Y-TZP (Lava)
crowns while such an improvement wasnt demonstrated
by Lorenzonis et al. study in the same year.
In contrary to his findings regarding single crowns,
Guazzato et al. 2004 stated that the strengthening
action of the Y-TZP is outweighed by the weaker
veneering porcelain in case of FPDs. This experimental
finding has been substantiated by number of clinical
studies that reported high incidence of chipping or
complete delamination of veneering porcelain. Poor
mechanical properties of the veneering porcelain and
a weak interface between zirconia core and veneer
are blamed for such complications. The former is a
well-accepted justification for minor chipping especially
when low fusing ceramics are used while some authors
cast doubt that the weak interface even exists. Bond
strength between zirconia core and veneering porcelain
was found to be similar to the bond in metal ceramic
samples used as controls (Al-Dohan et al. 2004). This
in vitro finding was substantiated by Raigrodski et al.s
2006 clinical study who reported absence of adhesive
failures at the interface after 3 years follow-up period.
However, the amount of evidence demonstrating the
role of -a weak interface- in zirconia FPDs seems to be
convincing (Aboushelib et al. 2007).

Clinical studies reported 73.9-100% survival rate of

zirconia all-ceramic FPDs over 2-5 years observation
periods. The most common complication (15% in 3
studies) was veneer layer chipping or delamination
(Sailer et al. 2007, Raigroski et al. 2006, and Vult von
Steyern et al. 2005). Framework fracture was a far rarer
complication and found to be as low as 0-2.2% in some
studies (Sailer et al. 2006, 2007). The high complication
rate in some studies may be worrying especially when
compared to survival rate of PFM FPDs which is 94.4%
for 5 years as estimated in the systematic review by Sailer
et al. 2007. However, Denry and Kelly 2008 remarked
that replacement of any restoration due to veneer layer
crazing or chipping was not needed. The oscillation of
complication and survival rates between different studies
necessitates careful interpretation and paying attention
to what is deemed to be failure. From a clinical point
of view, the restoration is successful if it does not need
further intervention or remaking, and it maintains health,
function and aesthetics (Ahmad 2006).
The amount of research tackling mechanical properties
of zirconia dental ceramics far exceeds that investigating
wear properties of this material. This is largely attributed
to the fact that wear properties of veneered zirconia
restorations are primarily dictated by those of the
veneering porcelain and the clinical applications of
unveneered zirconia are not so popular and limited to
cases of lack of interocclusal clearance, compromised
abutments and resin-bonded and inlay-retained zirconia
FPDs. In 2010, two papers published on the wear of
unveneered zirconia, one investigated the antagonistic
tooth wear (wear of the tooth structure opposing to
restoration) and found that unveneered zirconia is
associated with a lower antagonistic tooth wear when
compared to polished feldspathic porcelain (Jung et
al.2010). The other study was by Albashaireh et al. who
found that wear resistance of the zirconia ceramics is the
highest when compared to others. These studies indicate
that zirconia ceramics are compatible to opposing
dentition and at the same time structurally stable. These
results may be promising and encourage the use of
unveneered zirconia especially in the era of improved
shading techniques of zirconia frameworks; however
the phenomenon of low temperature degradation
alternatively called aging- that causes slow material
deterioration when exposed to wet environment is still
troublesome and concerning.
Bonding to zirconia poses a big challenge in some
clinical situations as surface treatments used with glass or
silica containing ceramics, e.g., hydrofluoric acid etching
and silanization, have been found to be ineffective
(Blatz et al. 2007). Use of adhesive cementation was
found to have no effect on the performance of zirconia
restorations, however it is still necessary when dealing
with cases of compromised retention as in the case of
short abutments or when using resin bonded zirconia

FPDs (Komine et al. 2010). Lack of bonding also

compromises the outcome of repairing delaminated
veneering porcelain layer. in vitro studies investigated
different surface treatments in attempts to overcome such
problems, tribochemical silica coating (e.g. Rocatec and
CoJet), plasma spraying, pre-treatment with phosphate
containing primers, airborne particles and etching with
CO2 laser were among those found to be effective.
However, a recent report by Behr et al. 2011 found that
silica coating and application of phosphate containing
primers in addition to silanization was insufficient to
attain a clinically acceptable bond strength which was
predetermined as 10 MPa.
Owing to their excellent optical properties, zirconia allceramic restorations are aesthetically appealing.
Absence of the black line at the gingival margins is an
important advantage of using white zirconia frameworks
over PFM restorations. Translucency and opacity of
zirconia frameworks vary between different systems.
For example, a 0.5mm thick core made of In-Ceram
Zirconia or Cercon is completely opaque, it is thus
recommended to be used in cases when masking
discoloured cores is necessary. On the other hand, Lava
frameworks are considered to be semi-translucent and
they are advantageous as they enhance the accurate
reproduction and depth of the natural tooth shade.
The introduction of coloured zirconia frameworks
hypothetically enhances the overall colour matching,
disputes the concerns about too white frameworks,
negates the need for liner application -which was
found to weaken core-veneer interface- and reduces
the thickness of veneering layer. Aboushelib et al.
2008 found that air-borne particle abrasion increased
bond strength of the core-veneer interface when used
with white zirconia framework in contrast to coloured
ones. Furthermore, they stated that application of liner
was found to enhance the bond in case of coloured
frameworks yet, a high incidence of de-lamination
was reported. Colored Cercon frameworks showed
higher core-veneer bond strength than Lava despite the
fact that their chemical composition was similar. They
attributed this to the structural changes occurring as a
result of different staining procedures. The significance
of using coloured zirconia frameworks was assessed
two years later by the same authors who concluded that
this technique did not offer any direct advantage over
the white zirconia frameworks layered with veneering
porcelain. Finally, Jung et al. 2007 investigated soft
tissue colour changes associated with veneered and
unveneered zirconia. It was found that zirconia did not
induce visible colour changes when thickness of mucosa
was 2 and 3mm. Also, the colour change that occurred
with 1.5mm thick mucosa was the least in case of
zirconia when compared to titanium. This may indicate
that gingival aesthetics are not affected when margins of
zirconia restorations placed in a sub-gingival location.
Results of in vitro and in vivo studies that proved high

Smile Dental Journal | Volume 6, Issue 2 - 2011| 9 |

biocompatibility of zirconia coupled with reduced

bacterial and plaque colonization when compared to
titanium encouraged the use of zirconia in implant and
restorative dentistry as a material with periointegrative
properties. Readers are referred to the excellent review
by Hisbergues et al. 2008 for more information about
the biocompatibility of zirconia and its applications in
implant dentistry.
Finally, there remain debatable questions to be asked
when all-ceramic zirconia restorations are concerned.
Firstly, if the tooth preparation guidelines are basically
similar to PFM restorations and zirconia has no
advantage over other types of all-ceramic restorations in
cases of limited inter-occlusal space and para-functional
habits, do we really get a benefit from substituting PFM
restorations with zirconia in terms of conservation of
tooth structure and dealing with difficult cases? Secondly,
does the gain from excellent aesthetic, mechanical and

biological properties outweigh the risk of restoration

failure -mainly delamination- which was found to be very
high in some studies? Thirdly, is there any guarantee
that zirconia restorations will not massively fail in a
manner analogous to zirconia heads used in total hip
arthroplasty due to low temperature degradation?
Answering these questions should be done through
conducting long term clinical trials exploiting the results
of in vitro research in hot topics like improving coreveneer interface utilizing different surface treatments and
testing aging-free zirconia ceramics namely, zirconia
toughened alumina and ceria-doped zirconia.

Acknowledgment

I would like to acknowledge with gratitude Dr. Brian

Nattress for the clinical photographs, Professor David
Wood for editing the paper and continuous support and
Dr. Hassan Maghireh for his kindness and motivation.

A clinical case of three-unit all-ceramic zirconia FPD over implants with an excellent aesthetic outcome. Zirconia abutments were used.

| 10 | Smile Dental Journal | Volume 6, Issue 2 - 2011